Q: If a patient requires a service or a piece of DME and is willing to pay for it up front, can I accept this payment or do I have to bill the insurance company first?
A: If the patient has active insurance coverage, the service or item is not identified as non-covered and you are a provider under contract with that insurer, you are obligated to bill the insurance company for the service or item such that the claim can be processed and appropriate monetary responsibility indicated in writing to the provider and the patient. If the item or service is deemed not medically necessary and therefore non covered by the insurer and you receive this notification in writing, you may bill the patient for subsequent same services if there is a waiver in place that specifies the date, service, charge and has a signature indicating the patients understanding of their financial responsibility. Waivers need to be specific and not generic forms that are signed at the initiation of services. This waiver should be maintained as a part of the patient’s medical record. If the service or item is non covered as specified in the patients evidence of coverage, and your provider agreement allows, you may bill the patient for the service, however it is still advisable but not required to have a waiver in place. Reference your provider agreement for more information on waivers and non-covered services.
Q: If a patient is involved in an automobile accident, and is covered under both commercial and auto insurance, who do I bill? Who can I accept payment from? How much can I accept?
A: If the patient has active medical coverage under a specific health insurer and you have a contract to participate with that insurer, you should bill the insurer as you would in any other case where litigation is not involved and should not accept as payment any more than is specified in your provider agreement with the specific insurer regardless of the number of payment sources involved.
Q: Do insurers process CPT codes the same for all providers or can rates differ for provider types?
A: Any discussions regarding contractual reimbursement rates should be conducted with the specific insurer.
Q: According to Medicare, I do not need a referral to see a covered patient. If I am only seeing the patient for an evaluation to develop an exercise plan for them, do I need to get any type of signed document from the MD?
A: Yes, a signed POC (plan of care) is needed to bill Medicare for any service, even an initial evaluation where no treatment aside from the evaluation was rendered.
Q: Where can I find information regarding the NPI and obtaining one for my office/corporation?
A: The Trailblazer Health website is the best resource for training materials and links to NPI applications. This may be accessed at www.Trailblazerhealth.com.
Q: If my company or corporation has not mentioned the NPI to me or the rest of the staff, what should I do?
A: Initiate the conversation; they will be glad you did!
Q: Can I defer copay collection?
A: Collection of copaymnents is a contractual obligation. Exceptions for those in financial hardship may be made, however this practice must be consistent across patients and is best kept at a minimum.
Q: My office administrator has CPT and HCPCS manuals that are only a few years old. Will these suffice to assist us in claims submission?
A: No. CPT codes are updated annually. Any office utilizing CPT in communicating procedures should maintain current editions of CPT, HCPCS and ICD-9 manuals.
Q: Can the VPTA or APTA take part in a negotiation meeting with a third party payer to support my efforts to improve my reimbursement rate?
A: No. In accordance with antitrust statutes professional organizations may not assist members in such endeavors.
